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Endocardite Infectieuse : Rôle de l’Echocardiographie

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Presentation on theme: "Endocardite Infectieuse : Rôle de l’Echocardiographie"— Presentation transcript:

1 Endocardite Infectieuse : Rôle de l’Echocardiographie
21ème Congrès du Collège National des Cardiologues Français Paris, 8-10 octobre 2009 Jean-Luc MONIN, CHU Henri Mondor, Créteil Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille

2 Diagnosis Management Role of Echocardiography
in Infective Endocarditis Diagnosis Management

3 Diagnosis Management Role of Echocardiography
in Infective Endocarditis Diagnosis Management

4 Modified Duke criteria for the diagnosis of Infective Endocarditis
MAJOR CRITERIA: - Blood cultures positive for IE - Echocardiography positive for IE: vegetation, abscess, new valvular regurgitation/ dehiscence of prosthetic valve MINOR CRITERIA: - Predisposing heart condition, IV drug abuse - Fever (> 38°C) - Vascular phenomena: arterial emboli, mycotic aneurysms, intracranial hemorrhage, … - Immunologic phenomena: Osler’s nodes, Roth’s spots, … - Bacteriological evidence: Positive blood culture but does not meet major criteria Li et al. Clin Infect Dis. 2000; 30: 633-8

5 Clinical Suspicion of IE
Trans-thoracic Echocardiography Prosthetic Valve Intracardiac device Poor quality TTE Positive TTE TTE Negative Clinical suspicion of IE High Low Transesophageal Echocardiography * Stop If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J Aug 27

6 Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent… Diagnosis of vegetation Diagnosis of abscess IE affecting intra-cardiac devices

7 Diagnosis of vegetation
Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… Diagnosis of vegetation Diagnosis of abscess IE affecting intra-cardiac devices

8 Diagnostic value for detecting vegetations: TTE versus TEE
- In 80 cases of endocarditis, sensitivity for the detection of vegetation was 58% for TTE versus 90% for TEE (p= 0.001). Mugge et al. J Am Coll Cardiol. 1989; 14: 631-8 Sensitivity (%) Specificity (%) Accuracy (%) Vegetations TTE (n=281) TEE (n=269) 79% 83% * 98% 99% 97% * P= NS : TTE versus TEE Monin et al. J Am Coll Cardiol. 2005; 46: 302-9

9 Henri Mondor Apical 4-chamber view Nunes

10 Apical 4-chamber (Lower plane)
Henri Mondor Apical 4-chamber (Lower plane) Nunes

11 Henri Mondor Color Flow Doppler Commissural leak (C2) Nunes

12 Clinical Suspicion of IE
Trans-thoracic Echocardiography Prosthetic Valve Intracardiac device Poor quality TTE Positive TTE TTE Negative Clinical suspicion of IE High Low Transesophageal Echocardiography * Stop If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J Aug 27

13 TEE : Inter-commissural plane
Henri Mondor TEE : Inter-commissural plane Nunes

14 Inter-commissural plane + CFD
Henri Mondor Inter-commissural plane + CFD Nunes

15 A negative TEE does not rule out endocarditis
Echocardiography (even Transesophageal) is not 100% sensitive Very small (< 2 mm) vegetation Non vegetant endocarditis Prosthetic and pacemaker endocarditis Mitral valve prolapse with thickened valves Vegetation not yet present or already embolized A negative TEE does not rule out endocarditis If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J Aug 27

16 Diagnosis of abscess Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent… Diagnosis of vegetation Diagnosis of abscess IE affecting intra-cardiac devices

17 Abscess of the aortic root
- Better assessed by TEE - Multiple views to assess abscess extension - Difficult diagnosis at the early stage of the disease - Need for frequent TEE controls if non operated Courtesy: Pr. C. Tribouilloy

18 Abscess of the aortic root: Better assessed by TEE
Courtesy: Pr. C. Tribouilloy

19 Abscess of the aortic root: Better assessed by TEE
Courtesy: Pr. C. Tribouilloy

20 Diagnosis of abscess Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent… Diagnosis of vegetation Diagnosis of abscess IE affecting intra-cardiac devices

21 Prosthetic valve endocarditis
- Better assessed by TEE - Especially in the mitral position - Reverberations/ artifacts due to the prosthesis - Need for frequent TEE controls if non operated Postoperative D-45

22 Prosthetic valve endocarditis:
The role of Transesophageal Echo Postoperative D-45

23 Adapted antibiotics (D+10)
Prosthetic valve endocarditis: Repeat TEE if non operated Adapted antibiotics (D+10)